MSA Referral

 
Case information:
 
   

Injured Workers' Name(First, Middle, Last):

Date of Birth:
Phone:
Address:
City, State, Zip:
Date of Injury:
Claim Number:
Employer:
HICN (Medicare #) and/or SS#:
Employer Address:
Employer Phone:
   
Key Contact & Billing Info:
 
   
Insurance Carrier/TPA:
Referring Party:
Adjuster Name:
Tel. Number:
E-mail:
Fax:
Defense Atty Name:
Tel. Number:
E-mail:
Fax:
Defense Firm Name:
Plaintiff Atty Name:
Tel. Number:
E-mail:
Fax:
Plaintiff Firm Name:
Please provide copies of the allocation report to:
Carrier/TPA
Party Responsible for Bill:
   
File Information:
 
   
Has Claimant applied, denied and/or appealing; or receiving SS Disability Payments?:
Is claimant currently Medicare Beneficiary?:
Has Claim Been Settled? If So, Please provide amount?:
Has the rated age been Obtained?:
 
Notes/Special Handeling:

 


Submit:
   

****Please provide the following Documentation:

1. Records from claimants treating physicians from past 2 years.
2. IME Reports from past year.
3. Consent to Release(x3).
4.Printout of payment history from past 2 years.
5. Medical Records.
6. Life Care Plan (if available).

 
 
 

 

 

 

  
   

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